Exposure to cold weather during a mass gathering in the Philippines.

PROBLEM: The visit of Pope Francis to the Philippines in January 2015 coincided with a tropical storm. For security reasons, the only road in and out of the area was closed 14.5 hours before the Pope's arrival. This meant that people had to wait for many hours with little shelter at the site. Medical teams in the field reported high numbers of people with cold stress during the mass gathering. APPROACH: To review the event from a public health perspective, we examined the consultations made by medical teams in the field and interviewed key stakeholders, focusing on cold stress as a public health risk. LOCAL SETTING: The key reason for the Pope's visit to Palo and Tacloban was the devastation caused in these cities by typhoon Haiyan in 2013. We estimated that the visit attracted 300 000 people. The medical teams were advised to consider cold stress risks two days before the event but no other measures were taken. RELEVANT CHANGES: Of the 1051 people seeking medical care, 231 people were experiencing symptoms of cold stress. People with cold stress ranged from 2 to 89 years of age and were more likely to be female than male, 173 (75%) versus 57 (25%). LESSONS LEARNT: Planning for mass gatherings should consider a wide range of public health risks, including cold stress. Improved data collection from the field is necessary to maximize the benefits of post-event evaluations and improve public health preparedness. Security measures to ensure the safety of key figures must be balanced with public health risks.

Hospital preparedness for Ebola virus disease: a training course in the Philippines.

OBJECTIVE: To develop, teach and evaluate a training workshop that could rapidly prepare large numbers of health professionals working in hospitals in the Philippines to detect and safely manage Ebola virus disease (EVD). The strategy was to train teams (each usually with five members) of key health professionals from public, private and local government hospitals across the Philippines who could then guide Ebola preparedness in their hospitals. METHODS: The workshop was developed collaboratively by the Philippine Department of Health and the country office of the World Health Organization. It was evaluated using a pre- and post-workshop test and two evaluation forms. χ(2) tests and linear regression analyses were conducted comparing pre- and post-workshop test results. RESULTS: A three-day workshop was developed and used to train 364 doctors, nurses and medical technologists from 78 hospitals across the Philippines in three initial batches. Knowledge about EVD increased significantly (P < 0.009) although knowledge on transmission remained suboptimal. Confidence in managing EVD increased significantly (P = 0.018) with 96% of participants feeling more prepared to safely manage EVD cases. DISCUSSION: The three-day workshop to prepare hospital staff for EVD was effective at increasing the level of knowledge about EVD and the level of confidence in managing EVD safely. This workshop could be adapted for use as baseline training in EVD in other developing countries to prepare large numbers of hospital staff to rapidly detect, isolate and safely manage EVD cases.

Three years of paediatric morbidity and mortality at the National Hospital in Dili, East Timor.

AIM: The aim of this study was to undertake a retrospective review of admissions and discharges to the paediatric wards at the National Hospital Guido Valadares, Dili, as the epidemiology of hospitalised children in East Timor cannot be easily understood from the hospital health management information system. METHOD: Data were sourced from unit registers for 3 years, 2008-2010 inclusive. Demographic characteristics and principal diagnoses were related to the risk of dying using stepwise multivariate logistic regression. RESULTS: There were 5909 children admitted to the wards over the study period and 60% were <2 years of age. The commonest reasons for admission were lower respiratory tract infections (LRIs) and gastroenteritis (43% and 16%, respectively). Severe malnutrition (MN) was recorded in only 5% of admissions. Overall, 6% of children died, mainly attributed to LRI (28%), central nervous system infections (16%) and MN (11%). Younger age, residence outside of Dili and admission during a busier period were independently associated with an increased risk of death. Nine per cent of hospitalised infants aged 1-6 months of age died and half of all deaths occurred within 2 days of admission. CONCLUSIONS: The study provides, for the first time, an understanding of the admissions and outcomes of the busiest paediatric inpatient unit in East Timor. It emphasises important health system issues which impact on both data quality and hospital outcomes.

Three years of neonatal morbidity and mortality at the national hospital in Dili, East Timor.

AIM: The aim of this study was to undertake a retrospective review of admissions and discharges to the neonatal unit at the National Hospital Guido Valadares, Dili, in order to gain insight into the epidemiology of hospitalised neonates in East Timor, as the information cannot be obtained from the hospital health management information system. METHOD: Data were sourced from unit registers for 3 years, 2008-2010 inclusive. Demographic characteristics and diagnoses were related to the risk of dying using stepwise multivariate logistic regression and adjusting for potential confounders of age, sex and weight. RESULTS: Two thousand eighty-eight babies were admitted to the unit over the study period. Over a quarter of babies weighed <2.5 kg on admission. Almost half were admitted from emergency or outpatient departments and only 27% were admitted within their first week of life. The most common reasons for admission were sepsis and respiratory disease (38 and 22%, respectively). Overall mortality was 11.4%, mainly attributed to prematurity (28%), infection (26%) and asphyxia (24%). Home birth, male gender, very low weight, young age and a short duration of hospitalisation were independently associated with an increased risk of death. Half of all babies weighing <1.5 kg died. Two-thirds of deaths occurred within 2 days of admission. CONCLUSIONS: The study provides, for the first time, an insight into the admissions and outcomes of the largest neonatal unit in East Timor. It is a baseline from which improvements to the quality of clinical care and data collection can be made.

The prevalence of common skin infections in four districts in Timor-Leste: a cross sectional survey.

BACKGROUND: Skin infections are a common public health problem in developing countries; however, they are rarely managed using a population based approach. Recent data on the burden of skin infections in Timor-Leste are limited. Our survey appears to be the only widespread survey conducted in more than 30 years and was designed to determine the baseline prevalence of some common skin infections in Timor-Leste. METHODS: We conducted a cross sectional survey in 14 sites including community health clinics, schools and hospitals within four different geographical regions. Participants were examined for five conditions (scabies, pyoderma, fungal infections, leprosy and yaws) by a multidisciplinary team. Analyses were conducted using EpiInfo version 6.04d. RESULTS: We examined the skin of 1535 participants aged between four months and 97 years. The majority of participants were male, aged between 11 and 20 years and had at least one condition of interest (56.0%, 56.0%, and 63.1%, respectively). Fungal infections were the most common presentation (39.0%) and males were more commonly affected than females (42.3% vs 34.0%, respectively, pvalue < 0.0001).Among those people with more than one condition the two most common co-infections were scabies with either pyoderma or a fungal infection (38.0% and 32.0%, respectively). The survey identified 29 previously undiagnosed cases of leprosy and six cases of yaws. CONCLUSIONS: Our findings indicate the need for a comprehensive programme to address these conditions. There are successful disease control programmes in place within the country and it is hoped a healthy skin programme could be integrated into an established disease control programme in order to maximise health benefits and resources.

An outbreak of severe infections with community-acquired MRSA carrying the Panton-Valentine leukocidin following vaccination.

BACKGROUND: Infections with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) are emerging worldwide. We investigated an outbreak of severe CA-MRSA infections in children following out-patient vaccination. METHODS AND FINDINGS: We carried out a field investigation after adverse events following immunization (AEFI) were reported. We reviewed the clinical data from all cases. S. aureus recovered from skin infections and from nasal and throat swabs were analyzed by pulse-field gel electrophoresis, multi locus sequence typing, PCR and microarray. In May 2006, nine children presented with AEFI, ranging from fatal toxic shock syndrome, necrotizing soft tissue infection, purulent abscesses, to fever with rash. All had received a vaccination injection in different health centres in one District of Ho Chi Minh City. Eight children had been vaccinated by the same health care worker (HCW). Deficiencies in vaccine quality, storage practices, or preparation and delivery were not found. Infection control practices were insufficient. CA-MRSA was cultured in four children and from nasal and throat swabs from the HCW. Strains from children and HCW were indistinguishable. All carried the Panton-Valentine leukocidine (PVL), the staphylococcal enterotoxin B gene, the gene complex for staphylococcal-cassette-chromosome mec type V, and were sequence type 59. Strain HCM3A is epidemiologically unrelated to a strain of ST59 prevalent in the USA, although they belong to the same lineage. CONCLUSIONS: We describe an outbreak of infections with CA-MRSA in children, transmitted by an asymptomatic colonized HCW during immunization injection. Consistent adherence to injection practice guidelines is needed to prevent CA-MRSA transmission in both in- and outpatient settings.

Evaluating the utility of surveillance data to decision makers in Victoria, Australia.

OBJECTIVE: Evaluating the utility of surveillance data to decision makers in Victoria, Australia. METHODS: A survey of all sexually transmitted infection program directors in Victoria, Australia, was undertaken to examine readership and use of annual and quarterly reports. RESULTS: One hundred and sixteen programs in 86 organisations were identified as undertaking sexually transmitted infection control activities in Victoria. Around 17% of the directors never read the reports and others reported not finding the information contained in them useful. While we found the information generated from the surveillance system has an important role in triggering action for epidemics and pervades more general decision making by improving the general knowledge of sexually transmitted infection trends, the indicators are not seen as useful by most key stakeholders. CONCLUSIONS: Significant improvements in the utility of the system could be made by changes to the data output and key suggestions made by the stakeholders are outlined.

Effectiveness of a publicly funded pneumococcal vaccination program against invasive pneumococcal disease among the elderly in Victoria, Australia.

Within Australia, Victoria is the only jurisdiction where the 23-valent polysaccharide pneumococcal vaccine (23vPPV) has been publicly funded for the elderly (aged > or = 65 years). We compared age-specific rates of invasive pneumococcal disease (IPD) for periods before and after implementation of the program, and data from a comparable Australian population that does not have a funded program. Vaccine effectiveness (VE) was estimated using the screening and indirect cohort methods. Compared to the pre-program period, there was a 36% reduction in the reported rates of IPD among persons aged > or = 65 years. Adjusted for under-reporting in the referent rate, the decrease was equivalent to an annual reduction of 112 cases and an estimated 14 deaths among persons > or = 65 years. VE was 71% (95% CI 54-82) using the screening method and 79% (95% CI -14 to 96) by the indirect cohort method. Both point estimates were consistent with the VE expected among persons aged > or = 65 years, although the small number of isolates meant the indirect cohort method was inconclusive at the lower 95% confidence limit. Consideration should be given to publicly funding pneumococcal vaccine for this age group in other settings.

Invasive pneumococcal disease in Australia, 2003.

There were 2,174 cases of invasive pneumococcal disease (IPD) notified to the National Notifiable Diseases Surveillance System (NNDSS) in Australia in 2003; a rate of 10.9 per 100,000 population. The notification rate varied between states and territories and by geographical region with the highest rates in the north of the country. Invasive pneumococcal disease was reported most frequently in children aged less than two years (98.8 cases per 100,000 population). Enhanced surveillance for IPD in 2003 was carried out in all states and territories, providing additional data on 1,842 (85%) of all notified cases. Rates of IPD in Indigenous Australians were three times the rate in non-Indigenous Australians. There were 125 deaths attributed to IPD resulting in an overall case fatality rate of 6.8 per cent. Seventy-one percent of all pneumococcal isolates serotyped were serotypes in the seven-valent conjugate vaccine and 91 per cent were serotypes in the 23-valent polysaccharide pneumococcal vaccine. The clinical presentation and risk factors for IPD varied between Indigenous and non-Indigenous cases and non-vaccine serotypes occurred more frequently among Indigenous children and adults. Data from three years of surveillance indicate an early impact of the 7-valent vaccine in the target population.

The pattern of notification and testing for genital Chlamydia trachomatis infection in Victoria, 1998-2000: an ecological analysis.

OBJECTIVE: This ecological study analyses routinely collected chlamydia notification and testing data to investigate any patterns. METHODS: Age and sex-specific chlamydia notification and testing rates for Victoria were calculated for the period 1998 to 2000. RESULTS: Chlamydia notification and testing rates rose between 1998 and 2000. Notification rates were higher among women aged 15 to 24 years than men of the same age (p < 0.01) and higher among 25 to 44-year-olds living in metropolitan rather than rural/regional Victoria (p < 0.01). Testing rates were higher for women than men (p < 0.01) and higher in metropolitan rather than rural/regional areas (p < 0.01) in all groups except women aged 15-24 years. CONCLUSIONS: These increasing rates highlight that chlamydia infection represents a substantial public health problem. IMPLICATIONS: Although these data provide useful information showing these rates vary with age and sex, formal epidemiological prevalence and risk factor studies are required.

Invasive pneumococcal disease in Australia, 2002.

There were 2,271 cases of invasive pneumococcal disease (IPD) notified to the National Notifiable Diseases Surveillance System in Australia in 2002; a rate of 11.5 cases per 100,000 population. The notification rate varied between states and territories and by geographical region with the highest rates in the north of the country. Invasive pneumococcal disease was reported most frequently in children aged less than five years (57.3 per 100,000 population). Enhanced surveillance for IPD in 2002 was carried out in all states and territories, providing additional data on 1,929 (85%) of all notified cases. Rates of IPD in Indigenous Australians were 2.7 times the rate in non-Indigenous Australians. The clinical presentation of IPD was most commonly pneumonia (44%) and bacteraemia (35%). There were 175 deaths attributed to IPD resulting in an overall case fatality rate of 9.2 per cent. Forty-two per cent of all cases had a recognised risk factor for IPD. Seventy-five per cent of all pneumococcal isolates serotyped were serotypes in the seven-valent conjugate vaccine and 93 per cent were serotypes in the 23-valent polysaccharide pneumococcal vaccine. The clinical presentation and rates of risk factors varied between Indigenous and non-Indigenous cases and non-vaccine serotypes occurred more frequently among Indigenous children and adults.